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AUTHOR AND EDITOR INFORMATION

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Author: Vikram S Dogra, MD, Professor of Diagnostic Radiology, University of Rochester School of Medicine; Director, Division of Ultrasound, Associate Chair of Education and Research, Department of Imaging Sciences, University of Rochester Medical Center

Vikram S Dogra is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, Association of Program Directors in Radiology, Radiological Society of North America, Society of Radiologists in Ultrasound, and Society of Uroradiology

Editors: Eric P Weinberg, MD, Associate Professor, Department of Radiology, University of Rochester Medical Center, Strong Memorial Hospital; Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; Arnold C Friedman, MD, FACR, Associate Chairman, Department of Radiology, University of Florida Health Science Center; Chief, Department of Radiology, Shands-Jacksonville Hospital; Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; John Karani, MBBS, FRCR, Consulting Staff, Department of Radiology, King's College Hospital, London

Author and Editor Disclosure

Synonyms and related keywords: hyperplastic cholecystosis, cholesterolosis, Rokitansky-Aschoff sinuses

INTRODUCTION

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Background

Differentiating between adenomyomatosis and cholesterolosis is difficult at times. Hyperplastic cholecystosis is the term used to describe cholesterolosis and adenomyomatosis.

For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center and Cholesterol Center. Also, see eMedicine's patient education articles Gallstones, High Cholesterol, and Cholesterol FAQs.

Pathophysiology

Adenomyomatosis is a benign condition characterized by hyperplastic changes of unknown etiology involving the gallbladder wall and causing overgrowth of the mucosa, thickening of the muscular wall, and formation of intramural diverticula or sinus tracts termed Rokitansky-Aschoff sinuses. Adenomyomatosis is a common tumorlike lesion of the gallbladder with no malignant potential and may involve the gallbladder in a focal, segmental, or diffuse form.

Etiology of cholesterolosis is unknown. Cholesterolosis is a local phenomenon unrelated to atherosclerosis. Triglycerides and cholesterol esters are deposited in the lamina propria of the gallbladder wall. Grossly, the lipid deposits are visible, lending the gallbladder wall a strawberry-like appearance—hence, the term strawberry gallbladder. The deposits vary in size and can be as large as 1 cm.

Frequency

United States

Adenomyomatosis is seen in 5% of cholecystectomies.

Mortality/Morbidity

Patients present with abdominal pain.

Race

No racial predilection is reported for adenomyomatosis.

Sex

Adenomyomatosis occurs more commonly in females.

Age

Adenomyomatosis occurs in patients with a mean age of 53 years (26-86 y). Case reports exist of occurrences in pediatric patients.

Anatomy

The normal gallbladder lies in the gallbladder fossa. The neck of the gallbladder has a constant relationship with the right portal vein, which helps localize the gallbladder on imaging studies. The normal gallbladder wall is composed of 4 layers: the mucosa, lamina propria, an irregular muscle layer, and connective tissue. Surface epithelium is composed of a single layer of columnar epithelium with basal nuclei and eosinophilic cytoplasm. No muscularis mucosa or submucosa exists. Along the hepatic surface, connective tissue is continuous with interlobular connective tissue of the liver.

Clinical Details

Patients usually present with vague abdominal pain and usually are treated symptomatically. Cholecystectomy rarely is performed to treat adenomyomatosis.

Preferred Examination

Ultrasound (US) is the preferred radiologic examination. Oral cholecystogram can be used to diagnose adenomyomatosis; however, use of US and MRI is preferred. MRI, CT, and positron emission tomography (PET) can be used as problem-solving modalities, especially to differentiate hyperplastic cholecystosis from gallbladder carcinoma.

Limitations of Techniques

Occasionally, US cannot differentiate between the segmental type of adenomyomatosis and gallbladder carcinoma.


DIFFERENTIALS

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Carcinoid, Gastrointestinal
Gallbladder, Carcinoma

Other Problems to be Considered

Differential diagnosis for tumors manifesting as intraluminal polypoid masses includes adenomatous, hyperplastic, and cholesterol polyps; carcinoid tumor; metastatic melanoma; and hematoma within the gallbladder.

Differential diagnosis for a mass replacing the gallbladder fossa includes hepatocellular carcinoma, cholangiocarcinoma, metastatic disease to the gallbladder fossa, and xanthogranulomatous cholecystitis.


RADIOGRAPH

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Findings

If Rokitansky-Aschoff sinuses are patent, oral cholecystogram demonstrates the characteristic appearance of sinuses filled with contrast.

In patients with cholesterolosis, an oral cholecystogram demonstrates the larger polypoid cholesterol deposits as fixed lucencies in the opacified lumen. The deposits are distinguished from gallbladder stones by a failure to move with compression and positional change. Sonography shows the lesions as nonshadowing, nonmobile intraluminal echoes.

Degree of Confidence

Radiography is not the preferred choice.


CT SCAN

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Findings

CT scans of adenomyomatosis reveal a thickened gallbladder wall with the rosary sign. The rosary sign is formed by the enhanced proliferative mucosal epithelium, with the intramural diverticula surrounded by the unenhanced hypertrophied muscle coat of the gallbladder.

Degree of Confidence

Findings on CT usually are confirmed further by other imaging modalities. CT is useful in excluding gallbladder carcinoma.


MRI

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Findings

MRI can be used in cases that are difficult to diagnose.

  • Gallbladder wall thickening with multiple intramural cystic components from Rokitansky-Aschoff sinuses can be visualized readily using MRI and is considered diagnostic of adenomyomatosis.
  • T2-weighted MRI breath-hold sequences are superior to other sequences in visualizing Rokitansky-Aschoff sinuses.
  • Diffuse-type adenomyomatosis typically shows early mucosal enhancement and subsequent serosal enhancement.
  • Localized adenomyomatosis exhibits homogeneous enhancement, showing smooth continuity with the surrounding gallbladder epithelium.

Degree of Confidence

MRI differentiates adenomyomatosis from cholesterolosis well.


ULTRASOUND

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Findings

  • Intramural cystic formation (anechoic diverticula) with echogenic foci and/or reverberation artifacts together with full or partial thickening of the gallbladder wall are considered to be the diagnostic findings on US examination. Reverberation artifact from cholesterol crystals is V-shaped and shorter in length than artifact from air. Sometimes, the calcium present within the sinuses may give rise to twinkle artifact.
  • On US, diffuse or segmental gallbladder wall thickening is evident.
  • Intramural diverticula may be seen. Diverticula containing bile are anechoic, and those containing sludge or stone are hyperechoic, with or without shadowing or reverberation artifacts.
  • If intramural diverticula are not identified, differentiating adenomyomatosis from other causes of gallbladder wall thickening, such as inflammation or carcinoma, is difficult.

Degree of Confidence

Segmental and focal adenomyomatosis may be difficult to differentiate from gallbladder carcinoma if characteristic features are not present.


NUCLEAR MEDICINE

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Findings

Small polypoid lesions of strawberry gallbladder can be differentiated successfully from gallbladder carcinoma using PET scanning with 18-fluorodeoxyglucose (FDG). PET reveals a focus of FDG uptake at the site of gallbladder carcinoma. No focal uptake is noted in cholesterol polyps.


ANGIOGRAPHY

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Findings

Angiography plays no role in the diagnosis of adenomyomatosis.


INTERVENTION

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No radiologic intervention is performed.


MULTIMEDIA

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Media file 1:  Longitudinal sonogram of gallbladder shows a hyperechoic focus in the anterior wall with reverberation artifact, which is characteristic of hyperplastic cholecystosis.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Image

Media file 2:  Transverse sonogram of the gallbladder shows multiple hyperechoic foci within the gallbladder wall with reverberation artifact. These findings are seen in patients with hyperplastic cholecystosis.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Image

Media file 3:  Oral cholecystogram shows focal fundal thickening in a patient with focal fundal adenomyomatosis.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  X-RAY

Media file 4:  Transverse sonogram in a patient with adenomyomatosis. Gallbladder wall is thickened, and many hyperechoic foci are seen in the gallbladder wall.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Image

Media file 5:  Sonogram in a patient with adenomyomatosis. Same patient as in Image 4.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Image


REFERENCES

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  • Franquet T, Bescos JM, Barberena J, Montes M. Acoustic artifacts and reverberation shadows in gallbladder sonograms: their cause and clinical implications. Gastrointest Radiol. Summer 1990;15(3):223-8. [Medline].
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  • Ishizuka D, Shirai Y, Tsukada K, Hatakeyama K. Gallbladder cancer with intratumoral anechoic foci: a mimic of adenomyomatosis. Hepatogastroenterology. Jul-Aug 1998;45(22):927-9. [Medline].
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  • Koh T, Taniguchi H, Kunishima S, Yamagishi H. Possibility of Differential Diagnosis of Small Polypoid Lesions in the Gallbladder Using FDG-PET. Clin Positron Imaging. Sep 2000;3(5):213-218. [Medline].
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  • Owen CC, Bilhartz LE. Gallbladder polyps, cholesterolosis, adenomyomatosis, and acute acalculous cholecystitis. Semin Gastrointest Dis. Oct 2003;14(4):178-88. [Medline].
  • Yoshimitsu K, Honda H, Jimi M, et al. MR diagnosis of adenomyomatosis of the gallbladder and differentiation from gallbladder carcinoma: importance of showing Rokitansky-Aschoff sinuses. AJR Am J Roentgenol. Jun 1999;172(6):1535-40. [Medline].

Adenomyomatosis excerpt

Article Last Updated: Dec 21, 2006